Relentless Health Value

It's hard for a payer to differentiate on cost or quality when it and all of its competitors are using the exact same PPO network. In this Summer Short, Stacey Richter talks with Jacob Asher, MD — a former ENT surgeon with Kaiser Permanente who spent 2008 to 2022 as a California commercial market medical director for Anthem Blue Cross, Cigna, and UnitedHealthcare — about why payers struggle to get providers to do anything special for their specific members, and why the "Dear Doctor" letters payers send to try to change that so often end up straight in the recycle bin.

WHAT YOU'LL LEARN

✅ Why providers contracted with multiple health plans have no real financial incentive to treat one payer's members any differently than another's

✅ Why standards of care between different payer policies rarely translate into actual differentiators in clinical practice

✅ Why the financial incentives providers face often don't reward standardizing or improving care in the ways payers want

✅ What kind of progress, if any, payers have made in getting providers more aware of the benefits available to their members

✅ Why providers are reluctant to hand off population health management to payers, even when it might make things easier

WHY THIS MATTERS

Payers keep trying to differentiate themselves through provider collaboration, but from the provider side of the desk, that collaboration usually looks like one more unopened letter in a stack of dozens from competing plans. Real differentiation, per Jacob Asher, would take genuine financial alignment and executional follow-through, not just clever messaging. Until that alignment exists, providers have little reason to treat any one payer's members differently, and patients keep experiencing the same fragmented care regardless of which plan is footing the bill.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

03:38 Why providers contracted with multiple health plans don't have a financial incentive to do something unique with one payer over another.

04:01 Why it doesn't make sense for providers to offer unique pathways for different payer organizations.

05:23 Why, broadly speaking, standards of care between payer policies aren't really differentiators in clinical practice.

06:47 Why financial incentives might not be aligned to make providers want to standardize their care.

09:16 What improvement has there been in plans making providers more aware of the benefits they offer?

11:47 Why won't providers off-load their pop health?

A supergroup, "Rolling Stone" once wrote, is a very fragile thing — balancing egos that are oversized from the start rarely produces something that lasts. Turns out, super ACOs (accountable care organizations) have similar problems: multiple ACOs or CINs, each made up of multiple practices under different ownership, trying to collaborate as frenemies rather than compete. In this Summer Short — cut from the full episode with Eric Gallagher (EP405) for reasons of time — Stacey Richter talks with Gallagher, CEO of Ochsner Health Network, about how Ochsner evolved out of a super ACO/super CIN structure and into its current value-based care model.

WHAT YOU'LL LEARN

✅ Why a "super ACO" — multiple ACOs or CINs, each made up of multiple practices, all under different ownership — tends to run into trust issues, infrastructure complexity, and process inefficiency

✅ Why rule number one of change management (create early "quick wins" so people can see success is possible) is especially hard to pull off when a structure is this complex

✅ What signs told Ochsner Health that its clinically integrated network structure wasn't going to get them to their outcomes goals

✅ Why CMS was a driver of the tough decision Ochsner ultimately made, and how changing the underlying economic model — not just the org chart — was the real fix

✅ Why scale matters for value-based contracts (you need it to afford the infrastructure and to earn a seat at the table) but why too much of it risks tipping into the kind of market power that invites bad behavior

WHY THIS MATTERS

Eric Gallagher's account of Ochsner's evolution is a real-world case study in exactly the recommendations Dan Serrano laid out in EP410, and it echoes the same "healthcare is local" theme from EP409 with Larry Bauer: what works in one market doesn't necessarily translate elsewhere, and rapid-scaling playbooks that ignore that keep tripping up investors and entrepreneurs. Building durable value-based care infrastructure isn't just an org-chart problem — it requires actually changing the underlying economic model, and knowing when a structure has gotten too complex to produce the quick wins that keep everyone bought in.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction

04:23 How Ochsner Health went from a super ACO to their current value-based care model.

06:09 What signs did Ochsner Health see that helped them recognize that the clinically integrated networks they were building wouldn't help them achieve the outcomes goals they were aiming for?

07:42 Why Ochsner Health's story is a classic example of change management.

08:41 What tough decision did Ochsner Health have to make that's ultimately led to much higher success rates?

10:46 "Really … it's about changing the economic model."

11:03 Why was CMS a driver of change?

13:00 What's the more sustainable business model in Ochsner Health's market?

15:09 How has Ochsner Health been ahead of the game in the healthcare market?

Provider organizations without capitated contracts or access to premium dollars are stuck in what Stacey Richter calls "the messy middle" — treating patients with chronic conditions well, without getting paid for the value they create. In this episode, Stacey talks with Dan Serrano, a healthcare finance consultant at COPE Health Solutions with 20+ years of experience across payers and providers (Aetna, Healthfirst, ChenMed, Mount Sinai), about the financial mechanics of payer-provider collaboration, using chronic kidney disease (CKD) as the worked example: a condition that's notoriously expensive, underdiagnosed, and undertreated, but where meaningfully better care is not actually hard to deliver.

WHAT YOU'LL LEARN

✅ Why CKD makes such a useful case study for payer-provider collaboration: two out of five ESRD patients don't even know they have kidney disease, and the local standard of care is often so low that meaningful improvement is genuinely achievable

✅ What the financial "messy middle" looks like for provider organizations that don't yet have capitated contracts or access to premium dollars, and why that's the stage where payer collaboration matters most

✅ Why payers have a real financial incentive to help local PCPs and provider organizations level up chronic care management, rather than relying solely on third-party point solutions to capture at-risk patients

✅ Why community-rooted clinicians consistently seem to outperform "snazzy tech" point solutions at actually moving the needle on chronic disease outcomes

✅ What a realistic timeline and risk-sharing structure looks like for a provider organization starting from shared savings and working toward eventually capturing a share of the premium dollar

WHY THIS MATTERS

The bar for improving CKD care is low enough that meaningful gains don't require heroic innovation — just payer-provider collaboration that gets local clinicians the financial support to actually manage these patients well. Every patient who falls through the cracks between a fee-for-service PCP visit and an expensive, unmanaged point-solution referral represents both a preventable cost and a preventable harm. As Dan Serrano lays out, the financial mechanics to fix that already exist; the work is building the collaboration to use them.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

09:08 What is the importance of payer/provider partnerships in reducing costs with chronic condition care?

10:52 Josh Berlin, JD, of rule of three; look out for his episode in a few weeks.

11:19 What's the endgame here with this payer/provider collaboration?

11:43 What advice does Dan have for providers who want to do better by patients with chronic conditions?

15:11 Who's driving costs in the system?

15:50 Why is lowering the average cost of chronic condition care important?

17:03 Why is there a meaningful delta between well-controlled CKD patients and those who aren't well managed or identified?

21:57 What does a realistic time horizon look like for addressing chronic condition care?

22:38 Why is it important to start in a shared savings place?

25:25 William Shrank, MD, of Andreessen Horowitz; look out for his episode in the fall.

26:35 Financially, what is the goal and how are we achieving a sustainable goal?

29:06 What is the balance between progress and risk here?

Frail elderly patients are among the most expensive and worst-served populations in American healthcare — and, as Larry Bauer puts it, everybody has a story about a family member who didn't "finish well." In this episode, Stacey Richter talks with Bauer, longtime CEO of the Family Medicine Education Consortium, about three innovative primary care programs built specifically around this population — each using a different payment model, in a different community, but converging on similar lessons about what it actually takes to deliver better end-of-life care.

WHAT YOU'LL LEARN

✅ Three real-world innovative primary care models for frail elderly patients: Dan Hoefer, MD, and Suzie Johnson's capitated Transition Program in San Diego; Ken Coburn, MD's CMS-grant-funded nurse navigator program, Health Quality Partners, in Pennsylvania; and Alan "Chip" Teel, MD's Full Circle America, a patient-funded home-monitoring program that costs roughly a tenth of nursing home care

✅ Why the same patient population (frail elders) requires genuinely different solutions depending on the local market — healthcare isn't one national market, it's hundreds of interconnected local ones, each with its own payer incentives and community relationships

✅ Why capitation, grant funding, and direct patient payment can all work as viable funding models for innovative primary care, as long as the program is actually rooted in and accountable to its local community

✅ How Larry Bauer thinks about the tension between right-sizing care and under-treating patients — the "death panel" counterargument these programs inevitably face

✅ Why trust between physicians, patients, and their communities — not technology or funding model alone — is the common thread across all three of these bright spots

WHY THIS MATTERS

"The number one goal is not cost containment; that's one of the outcomes," as one of the innovators featured puts it. These programs weren't built to save money first and help patients second — the cost savings followed from actually delivering care rooted in trust and local community relationships. For policymakers, payers, and self-insured employers looking for a single scalable model to roll out everywhere, that's an uncomfortable but important lesson: what works for frail elderly patients in San Diego won't look identical to what works in rural Pennsylvania, and pretending otherwise is how well-intentioned programs fail to actually help the people they're meant to serve.

MENTIONED IN THIS EPISODE

EP326 with Rishi Wadhera, MD, MPP: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

06:53 In a brief overview, what does end-of-life care in America look like?

10:38 What are the three innovative systems and physicians Larry Bauer has worked with?

14:27 What does it mean to be in a capitated system?

19:14 What does the Health Quality Partners system look like?

22:13 Andreas Mang from Blackstone; look out for his episode in September.

22:50 What is a number one reason for hospital readmissions?

23:26 The third example of innovative primary care.

27:04 Why is comprehensive care at the community level so important and successful for end-of-life care?

28:03 "The number one goal is not cost containment; that's one of the outcomes."

28:26 What is the core issue for these three types of innovative care?

31:02 What does good policy to encourage this type of innovation look like?

34:14 Why is it important to trust physicians and be present and partnered with physicians?

Does Comprehensive Primary Care Reduce Patient Access? With Vivek Garg, MD, MBA (Summer Shorts 3)

Answering the Access Objection to Comprehensive Primary Care. Summer Shorts 3.

Does making primary care more comprehensive necessarily mean seeing fewer patients? In this summer short, Stacey Richter talks with Vivek Garg, MD, MBA, chief medical officer of Humana's CenterWell and Conviva primary care organizations, about the common objection that comprehensive primary care reduces access — especially in areas already short on primary care doctors.

WHAT YOU'LL LEARN

✅ Why the assumption that better, more comprehensive primary care must reduce throughput and patient access doesn't hold up under Dr. Garg's framing

✅ Why a five-minute visit, even though it technically counts as "access," often isn't the kind of access that actually improves patient outcomes

✅ How advanced primary care models can change which PCP responsibilities are even necessary — potentially freeing up capacity rather than consuming it

WHY THIS MATTERS

Access is often measured by simple counts of visits or appointment availability, but this clip argues that a rushed, five-minute visit and a well-coordinated, comprehensive visit aren't equivalent forms of access at all. If advanced primary care models change what a PCP actually needs to do, the tradeoff between comprehensiveness and access may be smaller than critics assume.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

02:31 Does advanced primary care reduce access to patients?

03:01 Are five-minute visits with patients really access?

04:17 Will advanced primary care provide outcomes that make certain PCP responsibilities unnecessary?

Why a Transformed Primary Care Practice Never Went Back, With Scott Conard, MD (Summer Shorts 2)

What Happened When Staff Tried to Undo a PCP Practice's Transformation. Summer Shorts 2.

When a new practice manager tried to reintroduce a transformed primary care clinic's old, overflowing-waiting-room way of doing things, the entire staff said no. In this summer short, Stacey Richter revisits a clip from her original conversation with Scott Conard, MD, DABFP, FAAFM, co-founder of Converging Health and a family medicine physician with more than 35 years of practice experience, about why a Queens, New York PCP practice's staff refused to go back to the old model once they'd transformed it.

WHAT YOU'LL LEARN

✅ Why the "before" state of an untransformed PCP practice — an overflowing waiting room mixing genuinely sick patients with everyone else — pushed patients toward suboptimal ER and urgent care use

✅ Why purely transactional care, with no systemic attention to the "in between spaces" outside of office visits, leads directly to uncontrolled chronic conditions and preventable acute crises

✅ What happened when a new practice manager tried to reinstate the old model — and why the entire clinical team, not just the physicians, refused to go back within days

✅ Why practice transformation has to change work life for the whole team, not just improve metrics, to actually stick once a new manager or leader arrives

WHY THIS MATTERS

Practice transformation efforts often get evaluated purely on clinical or financial outcomes, but this clip shows a different kind of proof point: when the change makes work better for the entire staff, not just leadership, the team itself defends it against reversal. That kind of buy-in — from receptionists and MAs as much as physicians — is what makes transformation durable rather than dependent on whoever happens to be in charge.

MENTIONED IN THIS EPISODE

EP391 with Scott Conard, MD: Apple Podcasts | Spotify | Other Apps

EP405 with Eric Gallagher: Apple Podcasts | Spotify | Other Apps

EP402 with Amy Scanlan, MD: Apple Podcasts | Spotify | Other Apps

EP409 with Larry Bauer, MSW, MEd: Apple Podcasts | Spotify | Other Apps

EP407 with Vivek Garg, MD, MBA: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

02:15 Why a transformed PCP practice didn't want to go back to the old way of doing things.

04:02 Can fee for service in the short term still benefit primary practice?

05:24 Scott Conard's new book, Which Door?

Why Hospital Antitrust Cases Are So Rare, With Brennan Bilberry (Summer Shorts 1)

3 Reasons Antitrust Lawsuits Against Consolidated Hospital Systems Are So Uncommon. Summer Shorts 1.

If hospital consolidation is as anticompetitive as critics say, why aren't more health systems getting sued over it? In this summer short, Stacey Richter talks with Brennan Bilberry, founding partner of Fairmark Partners, a law firm litigating antitrust cases against dominant hospital systems, about three structural reasons private antitrust litigation against hospitals remains rare — revisiting his original conversation on the topic, EP395.

WHAT YOU'LL LEARN

✅ Why a continuing lack of price and contract transparency makes it hard to even know whether a hospital system's conduct is illegal, let alone prove it in court

✅ How the political power of hospitals as major local donors makes legislatures reluctant to pass laws that would make antitrust litigation easier to bring

✅ Why the FTC is "a little toothless" when it comes to tax-exempt, nonprofit hospital systems — even when their market conduct resembles what a for-profit monopolist would be punished for

✅ What certificates of public advantage are and how they can shield anticompetitive hospital mergers from ordinary antitrust scrutiny

✅ Why private antitrust litigation is an important recourse when transparency gaps and regulatory limits leave hospital systems largely unchecked

WHY THIS MATTERS

Hospital consolidation has reshaped local health care markets for years, but the legal tools meant to check anticompetitive behavior — transparency requirements, FTC enforcement, state legislation — all have real gaps that dominant systems can exploit. Brennan Bilberry's work at Fairmark Partners shows why private litigation has become one of the few levers left when regulators are outmatched by hospitals' political and financial power.

MENTIONED IN THIS EPISODE

EP395 with Brennan Bilberry: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

00:23 Healthy Economist's review of Relentless Health Value.

00:52 Why aren't more people suing hospitals?

01:16 How is the lack of transparency diminishing the number of lawsuits?

01:41 Why is the FTC "a little toothless" when it comes to nonprofits?

02:35 Why aren't there as many antitrust cases as there are instances of antitrust laws being broken?

03:10 Has consolidation of hospital systems been good or bad?

03:45 What quirk in the law creates an impediment for the FTC?

04:17 What are certificates of public advantage?

05:03 Why is private antitrust litigation important?

Behind the Scenes: RHV's Summer Shorts Plans and a CKD Update, With Stacey Richter (INBW38)

Why RHV Is Running Summer Shorts This Year — Plus What Stacey's Up to Outside the Mic. INBW38.

What happens to the good five-to-ten-minute clips that get cut from a 32-minute episode for time? In this InBetweenisode, Stacey Richter shares three listener voicemails responding to her EP399/EP400 manifesto, unveils "Summer Shorts" — a season of short-form clips pulled from the cutting-room floor of past interviews — and gives an update on her CKD (chronic kidney disease) work at QC-Health.

WHAT YOU'LL LEARN

✅ What prompted Stacey to start "Summer Shorts" — roughly half a dozen strong five-to-ten-minute insights that got cut from full episodes for time, not bloopers, now getting their own release

✅ Why listener voicemails from Doug Pohl, Justina Lehman, and Amy Scanlan, MD, underscore how isolating healthcare transformation work can feel — and why community matters

✅ How QC-Health is applying the same clinical-guideline-improvement process that lifted end-stage liver disease guideline use by 23% in six months to chronic kidney disease, where 50% of dialysis patients "crash into" dialysis via the ER and two in five had no idea they had CKD

✅ What else is on deck for the summer, including Stacey's Healthcare Influencer of the Year award from the Validation Institute and an upcoming keynote at the Pittsburgh Business Group on Health Symposium

WHY THIS MATTERS

The work of trying to fix a system this large and this entrenched can feel lonely and slow, which is exactly what this episode's listener voicemails speak to — the value isn't just in the insights, it's in knowing other people are in the trenches too. Summer Shorts also solves a real production problem: strong material that didn't fit a single episode's thesis doesn't have to just disappear.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

01:14 Doug Pohl's manifesto.

02:43 Justina Lehman's thoughts on why our podcast listeners are important.

04:05 Dr. Amy Scanlan's voice mail.

04:39 Note from Rajiv Patel, MD, MBA, FACP.

05:01 Relentless Health Value's plans for the summer.

09:18 Stacey's plans for the summer.

The Truth About PBM Rebates and Formulary Exclusions, With Scott Haas (Encore EP365)

Why "Rebate" in a PBM Contract Can Mean Whatever the PBM Wants It To. Encore Episode 365.

Only about 40% of the dollars a PBM collects from a pharma manufacturer's so-called rebate actually make it back to the plan sponsor as a rebate — the rest gets renamed an administration fee, a data fee, or a clinical program fee. In this encore episode, Stacey Richter revisits her conversation with Scott Haas, senior VP at USI Insurance Services, about how PBM rebate contracts actually work, why formulary exclusions punish cheap generics, and what it takes to negotiate a PBM contract with real, absolute pricing terms.

WHAT YOU'LL LEARN

✅ How the two-part rebate transaction works: pharma pays the PBM cash back to get formulary access, then the PBM promises to pass "100% of rebates" back to the plan sponsor — except only about 40 cents of every rebate dollar is actually labeled a rebate

✅ Why one insulin manufacturer's $350 list price per script nets out to just $52 after rebates — an 86% cut that shows how large the gross-to-net bubble has gotten

✅ Why cheap generics get excluded from PBM formularies in favor of expensive brands: generics don't carry rebates, so PBMs lose money when a high-rebate specialty drug goes generic

✅ Why Scott Haas says the only fix is a PBM contract that defines actual dollar prices per unit — not percentages off AWP or WAC, either of which can shift at any time

✅ How GPOs the "Big Three" PBMs have spun up further aggregate and maximize the rebate dollars at stake

WHY THIS MATTERS

The word "rebate" has become close to meaningless in PBM contracts, since a PBM can define it however it wants — which means a plan sponsor promised "100% of the rebates" can still be paying far more than it thinks. Scott Haas's bottom line is simple: whoever controls the definition of the deal controls the price, so plan sponsors need contracts with real, absolute dollar figures instead of percentages and acronyms that can quietly shift over time.

MENTIONED IN THIS EPISODE

EP342 with Christin Deacon: Apple Podcasts | Spotify | Other Apps

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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=== CONNECT WITH THE RHV TEAM ===

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00:00 Introduction

10:34 What's the major flaw with the buyer-seller relationship between plan sponsors and PBMs?

12:08 What are the five things that need to be considered in order to get a fair price from a PBM?

13:21 Why does using average wholesale price cause problems for plan sponsors?

15:10 What does it mean to put the network risk on the PBM?

17:15 What's happening with drugs moving from specialty brand to specialty generic?

19:19 "A generic is a generic; in our world, it's binary."

23:36 "The term 100% of rebates is really irrelevant."

23:59 What does it mean to have a minimum guarantee in drug rebates?

26:43 "When you do a line-item assessment … is it producing an optimal result in comparison to competitively achieved … pricing for generics … and for specialty?"

27:57 "Plan sponsors need to grow a backbone."

29:10 Why do you need to understand your consultant's process as a plan sponsor?

29:36 Why do you need to understand formulary exclusions as a plan sponsor?

29:46 Why is it important to create a more equal PBM contract?

30:57 "Rebates inure to the benefit of the plan sponsor; they don't necessarily benefit the consumer."

31:50 What does Scott do at USI?

Self-insured employers are the fiduciary of their own health plan under the Consolidated Appropriations Act — a fact carriers are increasingly using as their legal defense when sued. In this episode, Stacey Richter talks with Chris Deacon, JD, a former state health plan administrator who managed healthcare benefits for over 820,000 public-sector lives in New Jersey and now runs VerSan Consulting, about the current wave of healthcare litigation: breach-of-fiduciary-duty suits against carriers, carrier-versus-hospital billing disputes, and taxing-authority challenges to nonprofit hospitals' tax-exempt status.

WHAT YOU'LL LEARN

✅ Why carriers being sued for breach of fiduciary duty are arguing that self-insured employers — not the carrier — are the sole fiduciary, and that it was the employer's own responsibility to catch any CAA-violating contract language before signing

✅ How cases like Bricklayers vs. Anthem, Mass Laborers vs. Blue Cross Blue Shield, and Member vs. Cigna are testing whether employers can actually get the claims data they need to fulfill fiduciary duties they may not have realized they held

✅ How the carrier-versus-hospital fight plays out from both directions: United vs. TeamHealth over alleged upcoding, and TeamHealth vs. United over alleged underpayment

✅ Why taxing authorities are starting to challenge nonprofit hospitals' tax-exempt status directly, including the Tower Health line of cases in Pennsylvania and Pittsburgh vs. UPMC

✅ Why Chris Deacon says the legal framework hasn't caught up with the current reality of how carriers, hospitals, and employers actually operate today

WHY THIS MATTERS

As Chris Deacon lays it out, the CAA already made self-insured employers the fiduciary of their own health plans — whether or not they realized it at the time they signed their carrier contracts. That distinction is now playing out in courtrooms across the country, and the outcomes of these cases will determine who actually bears legal and financial responsibility when a plan fails to serve its members well: the carrier that wrote the contract, or the employer that signed it without the leverage or the data to know better.

=== LINKS ===

🔗 Show Notes with all mentioned links: Episode Page

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00:00 Introduction.

04:47 What does the current legal landscape look like, and how does it bode for the future?

07:24 "We need to catch the legal framework up with the current reality."

19:53 How is this first circuit decision affecting who might be found liable in future cases?

21:38 What happened in the Member vs Cigna case?

24:49 Are we heading in the direction of the employer having fiduciary responsibility?

25:47 What's happening in the Carrier vs Hospital cases?

28:49 Who's really paying the price for the current business practices being examined in court?

30:00 What's happened in the Tower cases?